1. The Tolerated Defects in Healthcare Introducing a new approach to safety in hospitals June, 2013 Roger Resar MD Senior IHI Fellow 1

2. The Task Despite current approaches to prevention, analysis and improvement hospitals continues to experience serious adverse events 2

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4. The Small Hospital Challenge Large scale projects promoted for large hospitals frequently do not apply (either by volume or nature) Staff time for team meetings is much less available Improvement skills are less available Resources are frequently very limited (travel, consultants, etc) 4

5. A New Concept 1-Projects are small with the entire emphasis on frontline driven identification.(meaning not top down) 2-All work on the project is done by a dyad in a dyadic fashion (meaning no teams) 3-There are no team meetings (meaning work takes place on the project as work takes place on the unit) 4-Has no relationship to a large change package (meaning every unit will have unique projects with little chance of sharing ideas unless the finished project is spread to other units in the organization) 5-The cost in resources to design the improvement is essentially nothing (meaning even small hospitals, clinics etc can afford the methodology) 6-Measurement is local with pencil and paper and emphasis is based on bimodal simplicity (meaning data collection is simple without need for IT) 7-Emphasis on JIT teaching rather than more formal quality improvement modules (meaning less cost, less time lost and better application of what QI knowledge the organization currently has) 8-Projects are finished in less than 30 days 5

6. Frontline Structured Conversation Frontline Structured Conversation Frontline Defects Clinical Non-clinical Collect Data Collect Data Suggest Strategies Suggest Strategies Identify Defects Identify Defects Frontline Engagement Small Tests Leading To Project Success Frontline Defect Driven Project Model

7. Surface Defects Surface Defects Scope Defects Validate Select specifi c work Design Strategy Finish Project Actions Design Benefits Timeline90 min2 Days1 day60 min 30 days Frontline Engagement Leadership Engagement Frontline Engagement Tester Engagement Frontline Engagement Design Basics of the Actions Conversation Specific Methodology Anchoring Questions Frontline Feedback Align work Gauge Capacity Articulate Implications Study the next defect Y/N Frontline Data Collection Determine frequency Define Boundaries Determine Simple measures Frontline Input Small Tests Frontline Defect Driven Project Framework R Resar

8. The Framework Multidisciplinary Team 90 Minute Visits ─Intro ─Identification of “defects”  Normalization of Deviation Non-threatening & blame free environment 8

9. Check List for setting up the Conversation Pre-arrange for a 90 minute conversation (preferably the conversation occurs on the unit) Pre-arrange a time for the conversation (chose a time when a representative group of frontline staff can participate) Invite a leadership representative 9

10. Technique to Start the Conversation Make introductions Have one lead person (others can participate later) initiate the conversation by asking individual frontline staff to describe their daily routine (without questions or interruption) Spend about 15-20 minutes in the start of the conversation (to allay fears) 10

11. Technique to Surface Defects Use anchoring questions to start to surface defects Examples: 1-We all have good and bad days at work, describe the last difficult day you recall? 2-Things have to be adjusted in work flow to make the day smooth, describe how you make adjustments to accomplish getting the work done? 3-What clinical diagnoses are most common on this unit, describe the most difficult cases you work with? 4-The unexpected is bound to occur from time to time, describe the last unexpected event that occurred in your work? 11

12. The Defects Each anchoring question usually surfaces at least one defect Most 90 minute conversations surface from 12-20 defects Avoid spending time on possible solutions (that will come later) Have a scribe write down each of the defects with as much detail as possible Finish the conversation by listing the defects surfaced, assure the frontline staff one or more of these will be solved and then thank the team 12

13. Some Observations Daily interruptions are commonly viewed as normal, so little or no attempt is currently made to change processes The units function primarily at an artisan level of work. Staff pride themselves in their unique ability to deal with defects (scrambling). “Victimized” by external factors. Most areas described problems with a system “out there”—units, physicians, scheduling systems, a physician’s preference and they are viewed as beyond their control 13

14. Cedars-Sinai Examples CVIC ─Patients arrive for a procedure still on anti- coagulation ─Daily search for equipment OR/PACU ─Cases delayed due to wrong equipment Radiation Oncology ─Add-ons ─Missing information 14

15. Cedars: Initial learnings It became clear that the seeds for the next event have already been sown in the day-to-day missteps described as “normal” by staff. Start small with the creation of small islands of stability. An island of stability represents an area of work that has been reviewed and changed to create a new standardized way to organize workflow. Build unit-based learning, reflection on work, measurement, and change leadership systems to support work at the local level. 15

16. MAYO CLINIC EXAMPLE

17. A Defect is Surfaced Can we fix it in 30 days? Study next occurrence of the defect Is it a re- surfaced defect? Document the defect Is the defect critical to patient safety? Are there resources to fix at unit level? Scope project > 30 days Is there interest in fixing the problem ? No Yes Can we fix it in 30 days? No Are there now interest, resources to fix ? Yes

18. Surface Defect Process Three one-hour conversations with the frontline Participants: Hospitalists Nurses Social worker Discharge planners Dietitian Pharmacists 39 defects surfaced during 3 conversations

19. Results 18/39 (46%) of surfaced defects moved on to improvement projects – 15/18 (83%) of surfaced defects that moved on to improvement projects were resolved in less than 30 days 2 projects qualified for ABIM/ABP MOC part IV (performance improvement) credit

20. CEDARS-SINAI EXAMPLE

21. One Week 33 Defects Identified 21 I Examples

22. What Was Learned It became clear that the seeds for the next event have already been sown in the day-today missteps described as “normal” by staff. Start small with the creation of small islands of stability. An island of stability represents an area of work that has been reviewed and changed to create a new standardized way to organize workflow. Build unit-based learning, reflection on work, measurement, and change leadership systems to support work at the local level. 22

23. Advantages Projects are accomplished by a dyad No team meetings No training other than JIT No data collection other than pencil and paper Creates enthusiasm for improvement 23

24. Session Objectives Understand how integral the harm measurement is to the mission and values of a hospital Explore the reasons for the lack of any significant improvement in safety in our hospitals Appreciate the key calibrations in the safety trajectory for a hospital

25. Surfac e Defects Surfac e Defects Scope Defects Validat e Select specifi c work Design Strategy Finish Projec t Actions Design Benefits Timeline90 min2 Days1 day60 min 30 days Frontline Engagement Leadership Engagement Frontline Engagement Tester Engagement Frontline Engagement Design Basics of the Actions Conversation Specific Methodology Anchoring Questions Frontline Feedback Align work Gauge Capacity Articulate Implications Study the next defect Y/N Frontline Data Collection Determine frequency Define Boundaries Determine Simple measures Frontline Input Small Tests Frontline Defect Driven Project Framework R Resar